Early referral for lung transplantation can be life-saving for people with pulmonary arterial hypertension (PAH). In this important review, van der Ploeg et al. explore when and how patients across major respiratory diseases especially Pulmonary Arterial Hypertension should be referred for transplant evaluation. As medical therapies continue to improve, the urgency and timing of referral have become more nuanced, yet no less critical.
Pulmonary Arterial Hypertension remains one of the most complex and high-risk conditions among transplant candidates. The authors emphasize that early referral is vital, given the unpredictable nature of right heart failure and the limitations of existing allocation systems such as the LAS (Lung Allocation Score), which often fail to capture the true severity of PAH. This has led to higher waitlist mortality for Pulmonary Arterial Hypertension patients in many countries.
Clinical guidelines from International Society for Heart and Lung Transplantation (ISHLT) and European Society of Cardiology/European Respiratory Society recommend referring patients for transplant evaluation if they:
- Are on optimal Pulmonary Hypertension therapy but still symptomatic
- Show progressive right ventricular failure, hypoxemia, or need intravenous prostacyclin
- Have a REVEAL risk score ≥ 7 or 8, indicating intermediate-high to high mortality risk
New therapies like sotatercept, which target vascular remodeling, may impact timing decisions in the future. Until then, referral decisions should be guided not only by clinical deterioration but also by risk models and functional indicators. Pre-transplant Extra Corporal Membrane Oxygentaion (ECMO) bridging is also recommended in select cases.
For patients, caregivers, and clinicians, the message is clear: Don’t wait for a crisis. Referral for lung transplant evaluation should occur before irreversible deterioration sets in. This allows time to optimize nutrition, treat comorbidities, build a relationship with the transplant team and increases the chance of a successful outcome.
Read more at this link on the NIH Library
Citation
van der Ploeg EA, Hylkema TH, Gan CT. Timing of lung transplant evaluation: considerations, barriers and alternatives. Curr Opin Pulm Med. 2025 Jul 1;31(4):354-358. doi: 10.1097/MCP.0000000000001176. Epub 2025 Apr 25. PMID: 40276963; PMCID: PMC12144536.